2 C/C and HPI “My arm keeps getting hurt” 18 yo male football player with recurrent history of arm pain. Has been having symptoms off and on since Symptoms were bilateral on occasion, but usually down one arm or the other. Three years ago, playing football while tackling, contact sent symptoms of pain, numbness and weakness down both arms. Patient doesn’t remember if he returned to play symptom free, however that football season, “every impact” he had would reproduce symptoms (down both arms or either arm). Parents noted continued weakness in his upper extremities two months after that football season. He didn’t play in 2008, and in 6/2009 while cutting the grass, patient lifted up his lawnmower and had numbness and tingling down his left arm.
3 HPI cont’dIn 2009, he played football without any symptoms, was evaluated for the first time in 2009 before playing.9/2010, had another episode, affecting his right arm. He initially stated this was his 1st episode of the year, however later on repeat f/u evaluation, he admitted that he would have symptoms a few times per week, but “they weren’t bad enough to tell anybody about it”.
4 Unremarkable PMHx, Sx, Fam Hx, Social Hx. No meds or allergies.
5 P.E.Gen: WN, WD NAD5’9” 160 lbsNeck Exam: no ttp along c-spine or paravertebral muscles, he did have ttp on his right trapezius muscle. Neck had FROM and full strength in all directions without symptoms. Spurling’s test was positive reproducing symptoms on his right and causing right trapezius pain.Neuro exam: CN II-XII intact, DTRs 1+ and symmetric in his upper and lower extremities, Motor strength was 5/5 and symmetric in all 4 extremities both proximal and distal.Negative Hoffman’s and inverted BR reflex.
10 IMAGINGStandard Cervical Spine X-Rays, shows no pathology except for loss of lordosis.MRI on 8/10/09: No disk bulging or protrusion present, normal vertebral body heights. No edema in the bones or spinal cord. No evidence of foraminal narrowing or spinal cord stenosis.MRI on 10/16/10: Normal cervical spine, C3-C4 level small bulging disc on the right, also some minimal disc bulging at C4-C5. No evidence of spinal stenosis. Loss of lordosis in the cervical spine. SAC 5.5mm
11 Sagital-diameter spinal-cord, spinal-canal, and vertebral-body diameter measurments. x = sagittal spinal-cord diameter, y = sagittal spinal-canal diameter, z = sagittal vertebral-body diameter.
12 Final working diagnosis Recurrent brachial plexopathySpear tackler’s spine.
13 Rx Relative Rest, Avoid Contact sports for now NSAIDS if currently symptomaticRehab/PT
14 OutcomeF/U in 3 months. With repeat films to see if there is return of lordosis of the cervical spine.
15 Return To ActivityOnce he has lordosis of his cervical spine and is asymptomatic, and has a normal strength and full range of motion. Will give him a trial of activity.
16 No Contraindications to Return to Play ** Single-level Klippel-Feil deformity/congenital fusion below C2Spina bifida occultaResolved stinger or brachial plexus neurapraxia (2 or less)Healed herniated discHealed subaxial cervical spine fracture (C3-C7)Healed facet fractureHealed lamina fractureHealed spinous process fracture (clay shoveler's fracture)Healed one-level anterior cervical fusionHealed single or multiple level posterior cervical foraminotomy
17 Relative Contraindications to Return to Play ** Resolved transient quadriplegia (1 episode)Resolved stinger or brachial plexus neurapraxia (3 or more)Non-healed/non-resolved asymptomatic herniated disc or severe foraminal stenosisHealed C1 fractureHealed C2 or Odontoid fractureAny healed subaxial spine fracture with minimal or mild residual displacement, deformity, or decreased range-of-motionHealed two-level anterior cervical fusionHealed one-level posterior cervical fusion
18 Absolute Contraindications to Return to Play or Participation ** Clinical or radiographic evidence of rheumatoid arthritis, anklosing spondylitis, or diffuse idiopathic skeletal hyperostosisArnold-Chiari malformationOs odontoidium or congential odontoid agenesis/hypoplasiaKlippel-Feil deformity/congenital fusion or anomaly involving C1 and/or C2Multiple-level Klippel-Feil deformity/congenital fusion below C2C1-C2 hypermobility or instability (ADI > 4 mm)Spear tacklers spine deformityTransient quadriplegia (2 or more episodes)Non-healed/non-resolved symptomatic herniated disc or severe foraminal stenosisCervical myelopathyMRI evidence of spinal cord contusion, edema, or abnormalityAny healed cervical spine fracture/dislocation (lateral mass fracture with subluxation/dislocation)Any healed cervical spine fracture or injury with residual instability > 3.5 mm/11°Any healed subaxial spine fracture with residual displacement, deformity, or decreased range-of-motionC1-C2 fusionThree-level (or more) anterior cervical fusionTwo-level (or more) posterior cervical fusionCervical laminectomy or laminaplasty